Sleep Assessment


Welcome to the Sleep Assessment! Please check off each statement that applies to you. Each is worth 1 point.

Name
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You always wake up too early in the morning
You wake up frequently throughout the night to use the bathroom
You have a hard time falling asleep
It’s hard to get to sleep because you feel tense and can’t relax
You wake up alert and ready to go between 2am and 4am and have a hard time getting back to sleep
You cannot get to sleep due to constant ruminations and negative thought loops
You seldom or never remember your dreams
You’re a night-owl and like to stay up late
You have frequent nightmares
You are driven and energetic even though you sleep little
You’ve had sleep problems since a prolonged period of stress or a single highly stressful event
You are unable to quit using caffeine
You have restless leg syndrome
You have leg cramps
Chronic pain when you are lying down keeps you from sleeping well
Your children’s insomnia keeps you from sleeping
You frequently need tranquilizers like Xanax, Ativan, and Valium to get to sleep
You frequently need Trazadone or Vicodin to help you sleep
You frequently use diphenhydramine (Sleepinal or Dramamine) over-the –counter medication
You need alcohol to sleep
You have sleep apnea
You use your phone, tablet, or computer after 7 PM
You have bright indoor lighting
Your pets sleep with you